Spandler, H. (in print) Crafting Psychiatric Contestation through single- panel cartoons. PathoGraphics: Narrative, Aesthetics, Contention, Community. Edited by S. Squier and I. Marei. Penn State University Press.

Introduction

It would be overstating things to claim that comics are inherently challenging or subversive. Nevertheless, given the genre’s radical counter cultural background, they are perhaps well-placed to critique prevailing practices and institutions, especially medical and healthcare systems (Williams 2011). As Ian Williams suggests, “there is something about the juxtaposition of drawings and handwritten text in comics that subverts the normal rules about what can be depicted, how it can be described, what one should think of that description and the subtle meanings and counter meanings that can be read into it” (2012: 25). In recent history, activists across a range of social movements have used counter cultural creative practices, especially comics and cartoons, as a form of resistance1. With this in mind, there have been recent calls for a more ‘critical’ medical humanities project that moves beyond the usual focus on the ‘illness experience’ and the ‘medical encounter’ to specifically engage with the counter-cultural creative practices of activist movements (Atkinson et al 2015; Viney et al. 2015).

The history of the treatment and management of ‘madness’ is complex and fraught.

Psychiatry, in particular, has emerged as a highly contested branch of medicine. Therefore, I

1 See, for example, The Nib https://thenib.com/ use the term ‘psychiatric contention’2 to refer to the way that dominant ideas, practices and policies in have been challenged and critiqued by psychiatric service users, survivors and their allies, supporters and social movements, including the Mad movement.

This chapter specifically explores the role of cartoons in this field of contestation. It relies on the idea that social movements have different ‘repertoires of contention’ (Crossley 2006) and suggests that cartoons are an increasingly important part of the growing repertoire of the psychiatric survivor movement. Therefore, I explore the role of cartoons in contesting, critiquing and challenging dominant medical and psychiatric framings of madness or ‘mental illness’.

This form of psychiatric contention is an important part of the emerging Mad Studies project, which explicitly de-centres professional psychiatric-centred knowledge about madness and produces alternative forms of mad-centred knowledge – i.e. knowledge formed through the individual and collective experience of the so-called ‘mad’ (Le Francois et al.

2013). For this reason, I primarily use the non-medical term ‘madness’ in this chapter (rather than mental illness or disorder) as it is the preferred term used by social movement activists in this field. I explore how cartoons have been used to actively challenge prevailing notions of normalcy, treatments and systems.

Single panel cartoons are one element within the broader ‘comic’ genre. In Understanding

Comics, Scott McCloud (1993) argues that there is a long-standing relationship between comics and cartoons, but they are not the same thing. Cartoons are a ‘style’, while comics are a medium which uses that approach. Comics tend to be seen as a form of ‘sequential art’

2 I use the term as a shorthand to refer to the range professions involved in mental health treatments and services. This may include nursing, social work, psychology, etc, as well as psychiatry. Whilst they are different (and somewhat competing) professions, psychiatry is presently the dominant way of framing statutory treatments and services. Whilst not strictly accurate, it feels preferable to using the more cumbersome academic term ‘psy professions’ that is often used. where a series of panels (usually consisting of graphics and text) constitute a story (or multiple stories). The single-panel cartoon can be distinguished from the multi-panel cartoon or comic strip/story in four main ways: the cartoon is contained within a single visual panel; there is less ongoing character development and ongoing story; and most importantly, it captures a message, and communicates it to the viewer in a simple, quick and digestible manner (Bradford-Lee 2015).

In the rest of this chapter, I present some examples of single-panel cartoons that have appeared in the UK-based magazine Asylum (the magazine for democratic psychiatry).

Asylum is an independent, quarterly magazine that was first published in 1986 and is still produced today. It was inspired by the Italian Democratic Psychiatry movement and the emerging psychiatric survivor movement. It features critical perspectives on mental health, madness and psychiatry by service users/survivors, their allies and mental health professionals. It publishes material in various formats, including articles, stories, cartoons, and poems. In 2015, it produced four special issues on the theme of mental health and comics.

This contribution is drawn from my research study exploring the first 30 years of Asylum magazine (1986-2016)3. I have identified a selection of cartoons that articulate key themes of psychiatric contention during that period. Here I describe, contextualise and analyse each cartoon’s contribution to a specific focus of psychiatric contention – notably ECT; self-harm; psychiatric diagnosis; and recovery. I suggest that they encapsulate key psychiatric critiques and communicate them in a vivid, accessible and often humorous way. Moreover, I make the

3 The research was funded by the Wellcome Trust (Bursary Award no. 208269/Z/17/Z): Crafting Psychiatric Contention: Asylum: the magazine for democratic psychiatry. case that they are a distinctive form of what Arthur Frank (2003) has called ‘survivorship as craft’ and tentatively suggest they are a particular ‘style’ of contestation, created by psychiatric survivors.

A few brief caveats are in order. The examples I give are by no means exhaustive: either of the styles of cartoons, or of the range of contested psychiatric themes illustrated though this medium. There are many other examples I could have used - within and beyond Asylum magazine. I have selected these few examples as they illustrate how cartooning has been a powerful means of communicating key concerns that have animated the psychiatric survivor movement during recent years. In doing this, however, I am aware of the danger of ruining the cartoons’ magic by interpretation and analysis. This is not unlike the problem with analysing jokes; which once explained, often cease to be funny. I am also aware of the sensitivity of interpreting the work of psychiatric survivors, who have often had negative experiences of psychiatric or psychological forms of interpretation and diagnosis. For these reasons, I am cautious about using the term ‘PathoGraphics’ as a way of framing this work.

Despite the alternative meanings intended by originators of this term, it is hard to separate

‘patho’ from ‘pathology’, and thus seeming to imply the importance of professional, medical and pathologising illness-framings (Frank 2017). Inadvertently, this may locate this work within certain frameworks, unintended by the artists. This concern is especially important to the psychiatric survivor movement which has actively resisted practices of ‘pathologisation’, medicalisation and co-option. For these reasons, I also purposefully focus my analysis on the cartoon’s socio-political contributions, and consciously desist from any psychological interpretations of the cartoonists.

I hope this endeavour is worthwhile in the following ways: First, by including examples of psychiatric contention within the growing graphic medicine field. Second, by helping to understand the contribution of comics and graphics to mental health survivor movements.

Third, by recognising, honouring and appreciating the distinctive craft developed by survivors as a form of resistance and critique.

1. Dorothy Nissen Sibley’s ECT cartoon

This first cartoon was created by Dorothy Nissen Sibley, an ex-psychiatric patient from the

US. It concerns one of the most contested forms of psychiatric treatment in the : electro convulsive therapy (ECT). This practice remains highly controversial, in part because it is still used today: mostly as a ‘last resort’ for people with severe ‘treatment resistant’ depression, especially older women. Indeed Asylum magazine has included regular critiques - and the very occasional defence – of ECT throughout its 30 years. For example, in

2014 it included a special issue: ‘Electroshock (ECT): brain damage as therapy’, put together by an ECT survivor who campaigns against this treatment. Sibley’s cartoon was included in the second ever issue of the magazine in 1986 (1.2:20); it appeared again in 2010 (7.3:26); and in the aforementioned more recent special ECT issue (2014: 23:3: 8).

Sibley’s cartoon succinctly illustrates some of the key criticisms of ECT. First, that it is usually carried out on women by a male-dominated psychiatric system: in the image the male doctor looms large over a female patient (there is little suggestion of gender ambiguity). The image clearly suggests the male doctor has significant power over the prone and helpless looking female patient. The second main criticism of ECT is that it is harmful and the threat of ECT used as a way to ensure compliance with treatment regimes. In the cartoon, the patient draws attention to the paradox of using something potentially harmful as a form of treatment. The cover image for the special ECT issue of Asylum shows a campaigner holding a ‘No forced shock’ placard, with the accompanying text, ‘brain damage as therapy’.

Sibley’s cartoon draws attention to the paternalism often used as a justification for this practice (the Dr says “I’m only doing this for your own good’). Sibley’s cartoon allows us to see this psychiatric critique very clearly, though the patient’s dark humour (expressed as

“what would you do if you were trying to hurt me?”), clearly suggests the treatment is ultimately experienced as harmful, not helpful.

The third main criticism of ECT is that it is often given without the patient’s full informed consent, and is therefore part of the regime of psychiatric ‘forced treatment’. This relates to a broader critique that psychiatry relies on compulsory treatment (and detention). Indeed one of the consistent demands from the psychiatric survivor movement has been for an end to compulsion and, specifically, forced ECT. The cartoon implies that whilst the patient is not activity resisting the treatment, she is certainly not actively consenting either. Whilst the doctor’s paternalism is voiced, through speech marks, the patient’s critique is unspoken; it is confined in a ‘thought bubble’. Speech and thought bubbles are common techniques used in the comic medium to show what can be voiced and what has been silenced. It is possible to illustrate this power imbalance through written prose, but ‘showing it’ arguably communicates this more clearly and vividly.

Historically psychiatric patients’ have often been reluctant to articulate their resistance, especially to their doctor, for fear of it being seen as further evidence of their ‘mental illness’ or ‘lack of insight’, as this may trigger further unwanted treatments. Therefore, a common form of patient resistance has been to fake compliance with treatment regimes, to avoid further hospitalisations and treatments which may be experienced as unnecessary or harmful

(Mills 2014). Sibley’s cartoon, in allowing viewers to see what is often left hidden and unspoken, potentially functions as a bridge between what James C Scott refers to as the

‘hidden’ and the more ‘public’ acts of resistance (1992). In summary, Sibley uses simple cartooning methods to illustrate key themes of psychiatric critique and resistance. The power of this cartoon to express those themes is evidenced by its repeat appearances in Asylum.

2. Tamsin Walker’s self-harm cartoons

All four single panel cartoons used in this section were created by Tamsin Walker, a UK illustrator who has personal experience of self-harm and is a psychiatric survivor activist4.

They all appeared in a special issue of Asylum on self-harm (entitled ‘minimising harm, maximising hope’) as stand-alone images alongside related articles on the subject (20.2:

2013). Therefore, they all neatly encapsulate another key theme of psychiatric contention: the

4 Walker has subsequently illustrated children books including a book for children about self-harm (Shaw and Walker 2015) and a graphic memoir about surviving abuse (Walker 2016) understanding and treatment of self-harm. As we shall see, they also, like Sibley’s ECT cartoon, highlight broader themes of contention.

Walker’s first cartoon5 neatly illustrates one of the key criticisms of the treatment and management of self-harm, that it often misses the point of the value of self-harm to the person:

Historically self-harm has often been misunderstood and misinterpreted as ‘parasuicide’, and self-harmers seen as attention seeking and manipulative. In the late 1980’s and early 1990’s an active self-harm movement began to emerge in the UK. Initiated by an alliance of feminists and psychiatric survivors, activists highlighted the way that people (usually women) who self-harmed were negatively treated by psychiatry and they campaigned for better understanding, support and services (Cresswell 2005).

5 This appeared in Asylum 20.2: p20 (2013)

In parallel, survivor activists attempted to create alternative understandings of self-harm as a

‘silent scream’; a coping strategy; and a reasonable response to intolerable situations (such as abuse and oppression). Thus whilst professionals might be understandably ‘concerned’ about a person self-harming, it is often experienced as having positive meaning and functions in a person’s life. Therefore, rather than setting out to stop self-harm all together, the self-harm movement has focused on supporting people to understand their self-harm and, if they do continue to self-harm, to do so more safely (Dace et al. 1998). Walker’s first cartoon neatly illustrates this theme through reversal and humour:

Presumably, an ‘appropriate’ answer to a standard question about one’s self harming behaviour (modified here to “So how is your self–harm going?”) would be to say either that it is ‘bad’ in some way or, more positively, that it has decreased or even stopped. If the former, the person would be seeking help from the mental health professional and if the latter, the person might even credit services for helping achieve this outcome. Instead, however, the woman smiles offers a surprising and unsettling response - “good thanks!” As self-harm is usually seen as necessarily damaging and dangerous, this cartoon neatly reverses our expectations and subverts our perceptions by suggesting that self-harm might actually be a valued activity for some people.

Walker’s second cartoon6 implicitly draws on this knowledge – which is well-known to self- harm activists – to ‘turn the tables’ on psychiatry and mental health professionals:

6 This appeared in Asylum 20.2: p21 (2013)

This cartoon cleverly questions the motivations of the mental health professional. It uses the technique of power reversal that is common to many critiques of psychiatry. Using satire, it attempts to make the case that the patient may actually be saner, more reasonable, or more rational than the professional. When the person (presumably a self-harmer) says to the mental health professional (“Dr”): “I’m concerned about the negative labelling you have been engaging in”, they are mocking the professional who expresses ‘concern’ about a person’s

‘self-harming behaviour’. Here, however, the problem is presented as the ‘negative labelling’ engaged in by the mental health professional, not the self-harm per se. This ‘labelling behaviour’ is seen to have a ‘negative’ impact on the patient, presumably by misunderstanding and labelling them as ‘manipulative’, ‘attention seeking’ etc. Here, in an unexpected twist, the professional ‘owns up’ to the function of their negative behaviour: it

“makes me feel less anxious”. The cartoon also prompts us to consider how unusual it is for professionals to own their feelings in this way. Indeed one of the exercises that self-harm activists initiated was to encourage professionals to consider their emotional reactions to self- harm and the ways they may self-harm in their own lives e.g. by over exercising; overworking and emphasises the ‘continuum of self-harm’ (Spandler 2018). Therefore, this cartoon shows it is not just self-harmers who use seemingly damaging activities to cope with their distress. Here, however, the negative activity is the ‘labelling’ of other people’s distress.

Therefore, the cartoon makes a broader critical point about the way that mental health services engage in ‘othering’ practices – defining, categorising and pathologising people’s reactions to distress.

This ‘negative labelling’ refers to particular stigmatising diagnoses which many self-harmers, especially women, often receive. As such, the cartoon also alludes to another key theme of psychiatric contention – the practice of psychiatric diagnosis. Whilst diagnosis is supposedly designed to benefit the client, this cartoon suggests it actually benefits the mental health professional, not the client, by relieving their anxiety. This effectively mirrors, in reverse, the experience of the survivor who uses self-harm to alleviate difficult emotions. Intriguingly, in doing so, it also opens up the possibility of seeing patients and professionals sharing a similar struggle with dealing with their anxiety and thus reveals a potentially shared humanity. In addition, it also breaks down the artificial boundary between the supposedly sane professional and the mad patient.

The practice of diagnosis as another theme of psychiatric contention is addressed directly in

Walker’s next cartoon7:

7 This appeared in Asylum 20.2: p27 (2013)

Psychiatric diagnosis has come under sustained criticism by survivors, mental health activities and academics. Critics frequently challenge diagnosis as unscientific, arbitrary, stigmatising, unhelpful at best, and damaging at worst. Indeed there have been campaigns to abolish psychiatric diagnosis in general (Timimi 2011) and, specifically stigmatising diagnoses like Schizophrenia and Borderline Personality Disorder (BPD) (Spandler 2014).

For example, another special guest-edited issue of Asylum was entirely devoted to critiquing

Borderline Personality Disorder (the title of the issue was “BPD: Bullshit Psychiatric

Diagnosis” (Asylum 14.3: 2004). BPD is the most common diagnosis given to women who self-harm but they often end up with an array of psychiatric diagnoses, including Complex

Post traumatic Stress Disorder and Attachment Disorder (also depicted on the cartoon dice).

BPD in particular has come under much criticism for being used to pathologise women’s ways of coping with abuse, oppression and adversity – seen as disorders of their personality rather survival strategies. Critics have argued that psychiatric diagnoses are not ‘evidence- based’ but are historically, culturally and professionally based value judgments. Moreover, psychiatric survivors often complain about the range of diagnoses they have received over the years in the mental health system, which relate as much to factors like which they saw, as to their underlying distress. Walker’s image ‘shows up’ the often arbitrary nature of diagnosis – like being dependent on the ‘roll of a dice’.

The last cartoon8 I use in this section vividly links the politics of self-harm to another key theme of psychiatric contention: the underfunding of mental health support services, especially under recent austerity policies:

Situated within a context of neoliberal austerity measures, on one level this message is very simple. “Stop the cuts” is a common demand of activists campaigning against reductions in support and services. But Walker’s cartoon neatly and implicitly links this to the ‘stop self- harming’ demand from services. As we have seen, the insistence on patients ‘stopping’ self- harming, despite the range of functions it may have for them, has been a key criticism levelled at psychiatric, psychological, and therapeutic practices. For example, mental health

8 Asylum 20.2: p26 (2013). services have been criticised for issuing ‘no self-harm’ contracts to clients, which meant if they self-harmed they would be denied support for a certain period of time. Indeed people who self-harm having adequate support, without an insistence that they give up their coping strategy, has been a key demand of self-harm activists who have advocated alternative harm- minimisation strategies.

Self-cutting is probably the most common form of self-harm, or at least the one which has been most well-articulated as a coping strategy. In the cartoon, the self-harmer is situated as demanding ‘no cuts’ - presumably to services - while they may continue to self-harm

(suggested by visible cuts to their arm). Here, again, the focus of the problem is not the self- harmer, but neither is it the mental health professional, or services - which are being defended

- but the broader political context (cuts to service provision).

Walker’s images use simple, but effective, cartooning methods, such as abstracted figures, speech bubbles and minimal accompanying text to convey a key message. By using reversal, subversion and humour they are able to illustrate key issues in the understanding and treatment of self-harm. Walker certainly wasn’t the first person to develop this style of contention in relation to self-harm. In fact, she explicitly drew on traditions developed by earlier survivor activists in the field. For example, one of the foundational texts of the growing self-harm movement, Self-Harm: Perspectives from Personal Experience,

(Pembroke 1994) included a series of single-panel cartoons called ‘Professional Thought

Disorder’, alongside powerful written testimonies of self-harm survivors. The cartoons reversed what is usually considered the ‘problem’, away from the self-harmer onto the professional who is supposed to be helping, through exaggeration and irony (Kilby 2001). Pembroke’s book is freely available on-line9 and the notion of professional thought disorder has become a common theme within the psychiatric survivor movement (for example, it is referenced in subsequent issues of Asylum). As ‘thought disorder’ is deemed a common symptom of mental illness, this idea is used to highlight the irrationality of the mental health profession, a system characterised as ‘thought disordered’, not the individual psychiatric patient. Walker’s cartoons implicitly draw on this notion and further illustrate it. Like

Sibley’s ECT cartoon, they also address broader themes of psychiatric contention (such as diagnosis and lack of funding for mental health support). Moreover, the cartoons, despite their seeming simplicity, convey a sophisticated and multi-layered critique.

3. Recovery in the Bin’s Unrecovery Star10

The next image explored here isn’t, strictly speaking, a ‘cartoon’. It lacks obvious cartoon- like qualities, such as abstracted figures and speech bubbles. However, as we shall see, it shares certain characteristics with cartoons, notably its use of subversion and mockery. I include it here because it illustrates the use of different techniques too. For example, it deploys a different ‘style’ of contention (‘spoofing’). In addition, whilst the other cartoons in this chapter were inspired by a collectively produced survivor knowledge, each was drawn by a single, identifiable individual. Unlike those, this image was, itself, collectively produced by a group of psychiatric survivors, as a parody of a well-known diagram used in service provision and training – the Mental Health Recovery Star. Whilst a standalone image, it requires specific knowledge of the image it parodies. Therefore, I include that image too:

9 http://www.studymore.org.uk/shpfpe.pdf 10 The Unrecovery Star appeared in Asylum 23.3: 18 (2016)

The Recovery Star

The Unrecovery Star

The past decade has seen the rise of ‘recovery’ orientated policy in relation to mental health care. This was initially viewed by many as a progressive and optimistic approach which would enable service users to live healthy, meaningful and productive lives, regardless of their mental health diagnoses, rather than being ‘written off’ as psychiatric cases. However, it has increasingly been criticised, partly due to the context within which it has been implemented (Costa et al. 2012; Harper and Speed 2012). For example, in the current context of austerity, recovery policy has often been used as an excuse not to provide people with disability benefits, support or services. As a result, ‘recovery’ has become a key contemporary theme of psychiatric contention. In the UK, a number of service users, survivors and their allies formed a campaigning group Recovery in the Bin (RiTB), explicitly to critique the ‘neoliberal recovery model’.

Activists involved in RiTB were especially critical of various recovery ‘measures’ and

‘indicators’. The ‘Recovery Star’ is one example commonly used in services across the UK to assess a person’s progress towards ‘recovery’. Whilst its domains include employment and relationships, many of the indicators have been seen as overly individualised, thereby seeming to place the responsibility for recovery onto the individual themselves and ignoring conditions that might support or prevent this. For example, whilst employment is often seen as an indicator of successful recovery, poor employment conditions are rarely perceived to be a barrier or problem. Therefore, the alternative ‘Unrecovery Star’ was designed to redress that balance.

Unlike the previous cartoons discussed in this chapter, the meaning and purpose of the

UnRecovery Star has been clearly articulated by its creators, on the RiTB website: see https://recoveryinthebin.org/unrecovery-star-2/ Therefore, rather than unpack the underlying

‘message’ of the image myself, I will just refer to their explication of it’. The UnRecovery

Star was specifically designed as a ‘social justice tool’ to highlight social inequalities and unmet needs e.g. housing and welfare. For example, it was developed to ‘highlight the reasons why we go Mad, but also what can hinder our ‘recovery’ and maintain our distress’.

Given the increasing pressure on service users to ‘recover’ (i.e. to get back to work, and not rely on disability benefits or ongoing support), the Unrecovery Star is used to suggest that

‘some of us will never feel ‘recovered’ due to the social and economic conditions we experience’. More generally, it is argued that ‘we need social and political solutions for social problems, which the UnRecovery Star simply and clearly identifies’ (my emphasis).

The UnRecovery Star is also interesting because it uses a technique different from those used in the cartoons examined earlier: the practice of ‘spoofing’ i.e. imitating something while mimicking, mocking or exaggerating its characteristic features for comic effect. In the

Unrecovery Star, spoofing is achieved by replacing the recovery outcomes in the first star with key social determinants like poverty, sexism, racism, homophobia/transphobia, inequality. This shifts the focus from the individual onto society, and suggests that key barriers to recovery are primarily social in origin. Spoofing is a common ‘style’ of contention used by other radical protest campaigns and social movements as a form of critique and resistance. Usually spoofing protests have targeted media advertisements. Using practices similar to graffiti art, activists deface existing adverts, alerting viewers to their underlying message, or creating new adverts, which explicitly parody existing ones. This practice was made popular by organisations like Adbusters in the US. http://www.adbusters.org/spoofads/ The Unrecovery Star shows us that psychiatric survivor activists have taken up these methods too. Indeed Asylum included a series of spoof adverts in its special Mad in Toronto issue (Asylum 2013: 20.4: 22-25). These targeted government- and psychiatry-endorsed anti-stigma campaigns which are seen as privileging an overly individualised and medicalised understanding of mental health. Therefore, these spoofing ads, like the other single-panel cartoons discussed here, function as a form of psychiatric contention. In a similar way, the Unrecovery Star uses parody and humour, in its mockery of the original recovery tool.

Psychiatric Survivorship as Craft and Conviction

The previous section explored how single-panel cartoons have illustrated key themes of psychiatric contestation that have animated the psychiatric survivor movement over recent years. In this final section, I tentatively suggest that psychiatric survivors have developed a distinctive ‘style’ of resistance and critique which, in turn, forms part of a growing repertoire of psychiatric contention. I explicitly draw on Arthur Frank’s notion of ‘survivorship’ (Frank

2003) which refers to the way that some people who have experienced illness and/or medical treatment are able to consciously transform their own suffering into public acts of witness and testimony. In other words, they are able to ‘craft’ their experiences in a way that displays an ethical-political responsibility to self and others. When Frank initially articulated this idea, he wasn’t explicitly referring to ‘craft’ in the sense of art or graphics11. He referred to the ethics of survivorship as a form of craft activity because, like craftworkers, they have a self- consciousness of purpose.

I make the case that drawing on comic and cartooning methods, survivors have crafted a distinctive style of psychiatric contention. In the examples given, the cartoons use humour, parody and subversion to consciously communicate their ‘critical ‘message’ in a quick, straightforward and direct manner. These images are crafted, at least in part, to evoke a shift in consciousness or recognition - about mental health and psychiatry. Indeed, Sheree

11 Frank (2017) has more recently explored graphic illness memoirs. Bradford-Lee (2015) argues that in single-panel cartoons, the ‘message is the star”. Cartoons are perhaps uniquely able to convey their message by what Scott McCloud calls

‘amplification through simplification’ (1993: 30). Rather than ‘dumbing down’ the message, cartoons amplify it (de Lappe 2015). By stripping down an image to its essentials, they not so much eliminate detail as focus on, and highlight, specific details.

Single-panel cartoons have been used to challenge accepted or prevailing attitudes and perspectives within psychiatric practice. Moreover, they can present alternative perspectives, outside the dominant bio–medical framing of ‘mental illness’. For example, in their own way, the cartoons used in this chapter offer up alternative explanations for such things as: why people are given ECT; why professionals use diagnosis; or why individuals might not

‘recover’. In addition, they offer alternative attributions of blame and responsibility – identifying the ‘problem’ as not the designated mad person, but the mental health professional; the mental health system; or wider society. They also subvert epistemological privilege, identifying the mad person as the source of knowledge and understanding, thus de- centring the role of mental health professionals. Crucially, a cartoon is able to achieve this without the use of inelegant academic language. This is important in a field where important critical ideas are often overly intellectualised and inaccessible.

A cartoon is able to cut through complexity and present contentious ideas in a vivid, direct and accessible way. This makes its message visible and potentially more digestible.

Therefore, it represents a form of critical pedagogy (or consciousness raising) which assumes people learn when their experience and emotions are engaged, rather than just their intellect.

By engaging other ways of knowing, cartoons are able to bypass our ‘normal’ and accepted ways of thinking and help us see things in a different way. In discussing the power of graphic illness memoirs, Frank argues that graphics give prose an ‘emotional jolt’ and helps

‘bear witness’ to suffering (Frank 2017). Pictures provoke our imagination and the accompanying prose helps to articulate and make sense of what the image provokes. Images

‘linger’ in the reader’s imagination. Whilst words and phrases linger too, images ‘linger differently’ (ibid).

Multi panel cartoons and graphic memoirs can also challenge dominant knowledge and understandings about mental health. Some notable examples of this genre in the UK include

Pembroke (1994); Brick (2010); Sen (2017); and Rowan-Olive (2017). Some of these are actually made up of single-panel cartoons which become a series, often using the same key protagonist, who is usually the illustrator/mad person/survivor. It has been suggested that single-panel cartoons are more clearly able to convey their message because they are less

‘muddied’ or ‘interrupted’ by storyline, character or plot development (Sheree Bradford-Lee

2015). Perhaps it is precisely because the focus of the single-panel cartoon isn’t about the character’s ‘illness story’, that enables it to offer a more structural critique.

However, this strength of the single-panel cartoon may also be its weakness. ‘Amplification through simplification’ inevitably risks erasing complexity. Of course, this is not unlike many other methods used to convey a political message, such as slogans, where messages are over- simplified in order to garner wider support for the cause. This tendency is especially risky in the field of mental health, madness and psychiatry. For all its endless controversies, the contestation of psychiatry is often rife with simplifications and polarised views. These can be distinctly unhelpful in building the alliances necessary to create positive change in mental health services (Mckeown 2009; Spandler and Mckeown 2016). For example, cartoons used to contest psychiatry may seemingly pit the patient against the professional as if they are necessarily oppositional categories. The ECT cartoon for example, may imply that all patients experience ECT as damaging, whereas views are divided and some individuals do report positive benefits (Rose et al. 2003; Sadowsky 2017). Moreover, the tendency to reverse the focus of ‘the problem’ onto psychiatry and mental health systems, doesn’t necessarily challenge the underlying binary logic. For example, the implication is that it is

‘really’ the professional who is mad or irrational, not the patient. This arguably still keeps the pathologising logic of psychiatry intact i.e. it retains the division between the ‘mad’ and the

‘sane’.

Notwithstanding these potential pitfalls, I have argued that single-panel cartoons are able to convey a message whilst also retaining a degree of complexity in presenting a multi-layered and sophisticated critique. Graphic memoirs can potentially and uniquely depict the complexity of illness, suffering and treatments, as the format doesn’t require an overarching written narrative. For example, Frank suggests that Allie Brosh’s Hyerbole and a Half (2013) is one of the clearest articulations of what he calls a ‘chaos’ story. Chaos is perhaps more

‘like’ the actual experience of illness, especially mental illness, than the prevailing

‘restitution’ narrative that tends to be preferred by the medical profession (which assumes medical intervention is benign and ultimately helpful). If graphic memoirs are able to challenge this dominant narrative by vividly portraying the patient’s actual experience, perhaps the single-panel cartoon is able to overtly politicise this challenge, which often remains implicit in the graphic memoir. For example, mental health ‘recovery’ policy is a variant of the restitution narrative which the Unrecovery Star explicitly rejects. Moreover,

Sibley’s ECT cartoon illustrates that medical intervention is not necessarily benign or helpful.

In addition, Walker’s cartoons not only subvert dominant understandings of self-harm, they also provide insight into the motivations of the mental health professional that may provoke understanding rather than merely reversal of blame i.e. that the professional may be using diagnosis to ‘relieve their anxiety’.

This style of psychiatric survivorship is an important part of the emerging Mad Studies movement. One of the aims of this movement is to ‘flip the microscope’ and ‘reverse the script’ (Costa 2014) by studying the practices, discourses and practices of normalcy and seemingly normal/sane people, rather than those deemed abnormal/insane by others. One of its key tenets is challenging the privileging of rationality and reason as key arbiters of truth and understanding. Cartoons are ideally suited to this task. They can bypass rationality and reason to embrace alternative ways of viewing the world. For example, one of the key components of the cartooning style is that it presents critique without having to provide evidence, logic or argument. Instead, it appeals to the collective knowledge of the psychiatric survivor movement as well as well-rehearsed critiques of psychiatry. Instead of evidence and argument, it uses emotion, humour and even ‘common sense’. For example, cartoons often appeal to certain cultural stereotypes such as the psychiatrist being ‘madder than their patients’; concerns about psychiatry ‘locking people up’; and sensibilities about giving people ‘electric shocks’. Notwithstanding concerns about oversimplification and stereotyping, they are also able to express rich, alternative experiential perspectives that people can relate to and even mobilise around.

Cartoons as Protest Companions

The ability of single-panel cartoons to convey a central idea is an important part of their appeal, both to individuals and – through their role in circulating challenging ideas - to a wider audience. Moreover, whilst reading multi-panel comics, including graphic memoirs, tends to be a solitary activity, single-panel cartoons lend themselves to a more collectivised reading. Appearing in newspapers and magazines (like Asylum), they are more readily talked about and shared. For example, single images can be more easily reproduced and shared across social media forums which are an increasingly important method of communication for activists. The Unrecovery Star has functioned in this way. Mental health activists have circulated and used it, explicitly as a social justice tool. Therefore, single-panel cartoons can be used not only to help individuals ‘hold their own’ (Frank 2010) in difficult encounters with professionals, but might even be used as protest ‘companions’ to social movements, similar to ‘companion species’ (Haraway 2003) or ‘companion stories’ (Frank 2010). In this context, I want to refer to another cartoon that has arguably functioned as a companion image in recent years. Dolly Sen, another UK-based psychiatric survivor and artist, created the following image in 2016:

The image was ‘inspired by her belief that madness comes from a broken heart rather than a broken mind, and the fear that psychiatry has about moving away from the broken brain hypothesis for explaining mental pain’ (Asylum 2016: 23.4: 4). The image was used as the emblem for the 2nd Mad Studies conference in the UK in 2016; it featured on the front cover of the special issue of Asylum magazine: ‘Mad Studies Comes of Age’ (Asylum 23.3); and, because of its popularity amongst psychiatric survivors, was used on pin badges given to delegates at Asylum’s 30th year anniversary conference in 2017. Participants at these events reported wearing this badge afterwards, in meetings and consultations with mental health professionals. Wearing this symbol of cheeky subversion – either visibly or in a more hidden way - seemed to offer a critical companionship to people facing challenging psychiatric situations and encounters. For example, a trainee mental health worker wrote: ‘I picked up a small pin badge with a heart and ‘pathologise this’ on it – this has become a sort of anchor for me and signifies and solidifies my way of being in the world’. This quote beautifully illustrates how this image might be seen as a ‘good companion’ to activists. Perhaps - like

Haraway’s companion species, and Frank’s companion stories - companion images have a kind of agency and co-exist with humans; they shape each other; take care of each other; and enable each other to be (Frank 2010).

It is worth noting here that most of the single-panel cartoons I identified during my research as examples of psychiatric contention were created by women12. In addition, the recent proliferation of zines and graphic memoirs have often been initiated within alternative counter-cultural communities (queer, trans, mad, autistic) and by other critical outsiders.

Moreover, they often reflect issues relating to mental health, gender, sexuality and normalcy, in both their content and style. This may be because cartoons are able to ‘express the thoughts that we’re afraid might label us as odd or strange, and even help to validate ourselves by normalising our behaviours’ (Bradford-Lee 2015: 19). Perhaps cartoons are a

12 Including all the cartoons I identified as part of my research, only a selection of which are presented in this chapter. particular style of resistance more likely to be adopted by certain marginalised, silenced and oppressed people. Having said that, it is worth noting that the cartoons I’ve cited here were created by, and depict, white protagonists. Therefore, this requires further exploration.

The tendency to use cartooning as critique may be related to humour historically being used a form of covert resistance by subordinated and oppressed people13. There may be several reasons for this. For example, it enables individuals to resist in less direct, confrontational, and thereby safer, ways. This is important in medical, and especially psychiatric, encounters where overt patient resistance may have severe consequences for the individual. Humour is often a way of communicating dissent: it can be hidden from those in power, but expressed and shared amongst the oppressed (Scott 1992). Cartoons, therefore, are a potentially effective way of making these hidden critiques more public and visible. In other words, borrowing a phrase from Audre Lorde, perhaps such cartoons help make survivors ‘available to themselves’ and this, in turn, makes their critique available to others. Indeed the increasing use of this medium in recent years might be related to the re-energised women’s movement, symbolised by the popular post-Trump #metoo campaign and the growing confidence of other marginalised communities in getting their voices heard. Given that autobiographic comics sprung from the radical 1960’s/70’s counter culture, perhaps it is not surprising there has been a resurgence in use of this medium in this newly politicised era.

In conclusion, I have made a case for single-panel cartoons as a distinctive ‘style’ of critique developed by psychiatric survivors which forms part of a growing repertoire of psychiatric contention within radical mental health movements. Survivor activists are drawing on creative traditions of art, subversion and humour to create new styles of psychiatric

13 It is important to acknowledge that cartoons and humour have also historically been used against oppressed people as well as by them. contention suitable for the social media age. Noting the role that cartoons can play in satirising contemporary politics, perhaps they are a good barometer, not only of key themes of psychiatric contention, but also of other key foci of socio-political resistance and critique.

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Acknowledgements

The author would like to thank the survivor artists whose work inspired this chapter. Also

Jill Anderson, Arthur Frank, Meg-John Barker and the editors of this volume who provided helpful feedback and suggestions for improving the chapter.

Biography

Helen Spandler, PhD is a Reader in Mental Health in the School of Social Work, Care and

Community at the University of Central Lancashire, Preston, UK. She has written extensively about mental health politics, practice and policy include, most recently co-editing Madness,

Distress and the Politics of Disablement (Policy Press). She is now the managing editor of

Asylum magazine and is keen to solicit more graphics, cartoons and comics http://asylummagazine.org/